ORAL habits IN ORTHODONTICS AND ,MANAGEMENT .pptx

CONTENT
Introduction TO ORAL HABITS
HABITS Definition
Classification
Thumb or digit sucking
Tongue thrust
Mouth breathing
Lip habits
Bruxism
Nail biting
Cheek biting
Masochistic habits

INTRODUCTION TO ORAL HABITS:
Oral Habits are the part of human development.
Infants, children or adolescents well-being can be very much affected by oral habits.
Oral habit behaviors include digit sucking, pacifier sucking, lip sucking and biting, nail-biting, bruxism, self-injurious, mouth breathing and tongue thrust.
HABITS DEFINITION:

Dorland(1957)-
Fixed or constant practice established by frequent repetition

Buttersworth(1961)-
Frequent or constant practice or acquired tendency, which has been fixed by frequent repetition.
Moyer
Habits are learnt pattern of muscle contraction of a very complex nature.


CARL O BOUCHER(1963)-
Habit as a tendency towards an act or an act that has become a repeated performance relatively fixed, consistent and easy to perform by an individual.




Mathewson(1982)-
Learned pattern of muscular contractions

FINN(1987)-
Defined habit as an act which is socially unacceptable
Classification
WILLIAM JAMES(1923)
Useful habit- Normal breathing, normal swallowing
Harmful habit- Mouth breathing, tongue thrusting

KINGSLEY(1958)
1) Functional- Mouth breathing
Muscular- Tongue thrusting
Combined- thumb sucking
Postural- chin propping, face leaning on hand, pillowing


Morris and Bohanna (1969)
1) Non pressure habit-Mouth breathing
2) Pressure habits-Thumb sucking, tongue thrusting
3) Biting habits-Nail biting

KLEIN(1971)
Empty hands- have no psychological association e.g., pencil biting
Have strong psychological affliction e.g., thumb sucking


FINN AND SIM(1987)
Compulsive habit- acquired fixation in child e.g., thumb sucking
Non compulsive habit- easily added or dropped e.g.,passive placement of thumb in the oral caviy

Finn(1987)
Primary habit- thumb sucking
2) Secondary habit- nose probing, hair pulling
THUMB SUCKING
It refers to placing the thumb or fingers into the mouth many times every day and night, exerting a definite sucking pressure.
The habit can be repetitive and forceful associated with strong cheek and lip contractions.
Several theories have been put forward to explain thumb sucking habit:
1) Freudian theory of psychoanalysis is linked to psychosexual development of human. This theory regards thumb sucking as a symptom of a deeper emotional disturbance or neurosis.


Abnormal oral habits: A review N. Shahraki, S. Yassaei* and M. Goldani MoghadamJournal of Dentistry and Oral Hygiene Vol. 4(2), pp.12-15, May 2012
2) Palermo Theory regards thumb sucking arising out of progressive stimulus and rewards reaction which would spontaneously disappear unless it becomes an attention getting mechanism.
3) SEARS ORAL DRIVE THEORY believes that the thumb sucking habit is intimately related to the prolongation of breast feeding. The longer the baby is breastfed, stronger will be its oral drive

1. GOOD MORNING

2. ORAL HABITS PRESENTED BY:

3. CONTENT Introduction TO ORAL HABITS HABITS Definition Classification Thumb or digit sucking Tongue thrust Mouth breathing Lip habits Bruxism Nail biting Cheek biting Masochistic habits

4. INTRODUCTION TO ORAL HABITS: Oral Habits are the part of human development. Infants, children or adolescents well-being can be very much affected by oral habits. Oral habit behaviors include digit sucking, pacifier sucking, lip sucking and biting, nail-biting, bruxism, self-injurious, mouth breathing and tongue thrust.

5. HABITS DEFINITION: Dorland(1957)- F ixed or constant practice established by frequent repetition Buttersworth(1961)- F requent or constant practice or acquired tendency, which has been fixed by frequent repetition .

6. Moyer H abits are learnt pattern of muscle contraction of a very complex nature. CARL O BOUCHER(1963)- Habit as a tendency towards an act or an act that has become a repeated performance relatively fixed, consistent and easy to perform by an individual.

7. Mathewson(1982)- L earned pattern of muscular contractions FINN(1987)- Defined habit as an act which is socially unacceptable

8. Classification WILLIAM JAMES(1923) Useful habit- Normal breathing, normal swallowing Harmful habit- Mouth breathing, tongue thrusting KINGSLEY(1958) 1) Functional- Mouth breathing M uscular- Tongue thrusting C ombined - t humb sucking P ostural - c hin propping, face leaning on hand, pillowing

9. Morris and Bohanna (1969) 1) N on pressure habit-Mouth breathing 2) Pressure habits-Thumb sucking, tongue thrusting 3) Biting habits-Nail biting KLEIN(1971) Empty hands- have no psychological association e.g., pencil biting Have strong psychological affliction e.g., thumb sucking

10. FINN AND SIM(1987) C ompulsive habit- acquired fixation in child e.g., thumb sucking Non compulsive habit- easily added or dropped e.g.,passive placement of thumb in the oral caviy Finn(1987) Primary habit- thumb sucking 2) Secondary habit- nose probing, hair pulling

11. THUMB SUCKING I t refers to placing the thumb or fingers into the mouth many times every day and night, exerting a definite sucking pressure. The habit can be repetitive and forceful associated with strong cheek and lip contractions . S everal theories have been put forward to explain thumb sucking habit : 1) Freudian theory of psychoanalysis is linked to psychosexual development of human. This theory regards thumb sucking as a symptom of a deeper emotional disturbance or neurosis . Abnormal oral habits: A review N. Shahraki , S. Yassaei * and M. Goldani Moghadam Journal of Dentistry and Oral Hygiene Vol. 4(2), pp.12-15, May 2012

12. 2) Palermo Theory regards thumb sucking arising out of progressive stimulus and rewards reaction which would spontaneously disappear unless it becomes an attention getting mechanism. 3) SEARS ORAL DRIVE THEORY believes that the thumb sucking habit is intimately related to the prolongation of breast feeding. The longer the baby is breastfed, stronger will be its oral drive and more prone it is to thumb sucking.

13. BASED ON DEPTH OF PLACEMENT OF THUMB (SUBTELNY, 1973) Type A - W hole digit into the mouth with the pad of thumb, pressing over the palate s een in 50% of children type b - T humb not touching the vault of palate s een in 13-24% of children TYPE C - T humb is placed just beyond the first joint contacting hard palate and maxillary incisors only. seen in 18% of children TYPE d - V ery little portion into the mouth seen in 6% of children

14. ACCORDING TO MOYER : PHASE I: N ormal and sub clinically significant sucking seen from birth to 3 years . I f vigorous sucking persists at the end of phase 1,it may be carried to the next phase, so preventive measures can be substituted by physiological barrier. Phase ii: c linically significant sucking seen in 3-7 years of age. It may be due to clinically significant anxiety and it is the best time to solve dental problems . Phase iii: i ntractable sucking, if habit persist into phase 3,the problem is more serious and will require psychotherapy .

15. ACCORDING TO COOK: ALPHA GROUP : The thumb pushes the palate in a vertical direction and displays only little buccal wall contractions. BETA GROUP: Strong buccal wall contraction seen and a negative pressure is created resulting in posterior cross bite. GAMA GROUP: Alternative positive and negative pressure is created.

16. ETIOLOGY PROLONGED SUCKLING FEELING OF INSECURITY IMPROPER/ INADEQUATE NURSING LEARNING PATTERN WITHOUT UNDERLYING CAUSE CHILD DEPRIVED OF PARENTAL LOVE AND CARE ATTENTION GETTING MECHANISM HABIT DURING ERUPTION OF TEETH FEELING OF PERSONAL INADEQUACY FEELING OF HUNGER

17. T ypes of malocclusion that may develop depends upon a number of variables Position of the digit Associated oro-facial muscle contraction The position of the mandible during sucking The facial skeletal pattern Effect of digit sucking on oral structures: The effect of any pressure habit is dependent upon the Trident of habit factors: 1) duration 2) frequency 3) intensity

18. D igit sucking results in development of features of Class ii malocclusion Proclination of the upper incisors is the first and most common sign of persistent thumb sucking The proclination is self-maintaining because of the cushioning effect of lower lips and upper lip becomes redundant These proclined incisors are prone to trauma.

19. VERTICAL AND HORIZONTAL EFFECTS: T he digit which is usually placed ventrally against the palate and against the lingual surface of the upper incisors, is positioned at an angle and forms a fulcrum which consists of the digit, the wrist and the forearm. Force produced by lever principle Vertical vectors Horizontal vectors As little as 35gms of force can tip a tooth. 4-6 hours of force per day is probably the minimum necessary to cause tooth movement

20. CLINICAL FEATURES E xaggerated mentalis activity may be seen because of the effort of the lower lip to attain a lip seal anteriorly. M axillary arch shows constriction due to unopposed pressure from buccal musculature . P osterior crossbite tendency may occur. Mandibular incisors may be retroclined or upright. Mandible experiences downward and backward rotation due to lowered position while sucking.

21. 5. An increase in ANB angle is seen due to both maxillary prognathism and mandibular retrognathism. 6. Patient may develop tongue thrusting due to appearance of spaces in the anterior region. 7. The thumb is cleaner due to frequent use in the mouth. Constant irritation from the teeth may cause formation of callus.

22. DIAGNOSIS HISTORY EXTRAORAL EXAMINATION THE DIGITS LIPS FACIAL FORM INTRAORAL EXAMINATION TONGUE DENTOALVEOLAR STRUCTURES GINGIVA

23. PREVENTION T here are various preventive measures which can be executed like: Motive based approach Engaging child in various activities Parents involvement in prevention Duration of breast feeding Mothers presence and attention during bottle feeding Using physiological nipple Using dummy/pacifier

24. SIX STEPS IN CESSATION OF HABIT (LARSON AND JOHNSON) S creening for psychological component H abit awareness Habit reversal with a competing response Response attention Escalated DRO(differential reinforcement of other behaviours) Escalated DRO with reprimands (consists of holding the child, establishing eye contact, and firmly admonishing the child to stop the habit)

25. MANAGEMENT A ccording to Forrestor(1981) three main areas should be considered in constructing treatment plan E motional significance of the habit T he age of the patient T he status of the child’s occlusion

26. EMOTIONAL SIGNIFICANCE OF THE HABIT T o determine whether the thumb sucking is a meaningful or an empty habit C onsultation with a psychiatrist is considered if the sucking habit is a symptom of an abnormal behaviour problem

27. TREATMENT OF AN INFANT (BIRTH TO 2 YEAR) T humb sucking during infancy is of no concern to the dentist or the parent if no physical effect is produced on the teeth W hen sucking is abnormally vigorous enough to displace the teeth the problem is of concern and also could act as a symptom of: 1)I nsufficient feeding 2)I nadequate love 3) Bored, unhappy or over fatigued child

28. N o attempt should be made to cure the habit in a malnourished or sick infant who may obtain significant gratification from it. F requently, the only treatment necessary may be a little more cuddling and playing with the child and simple instruction to the mother in the technique of feeding the infant .

29. TREATMENT IN A PRE-SCHOOL CHILD(21/2 – 3 YEAR) A t these years, child begins to assert his/her independence from the mother and inevitably tensions and frustrations may occur causing an occasional short-lived sucking episode. In the pre-school child thumb sucking which is practiced only before going to bed may be disregarded being a benign activity, and correction may prove harmful. However if it is frequently indulged during the waking hours, the child is over fatigued bored or unhappy, then suitable factors in the environment should be corrected.

30. TREATMENT IN 3-7 YEAR OLD T his age group child may be more of a concern depending on the type of habit and whether the child is pulling the maxilla anteriorly or just sucking his digit with buccal constriction . T he child with good molar intercuspation and little anterior pull i.e., the passive sucking child should be counseled and the dentist should work along with the parent with contingent behavior modifications . 90% children stop by the age of 3-6 years. If continues beyond that it needs to be treated.

31. TREATMENT APPROACH T reatment to be initiated between 4-6 years, with child’s willingness 1) Counselling 2) Reminder therapy 3) Reward system 4) Adjunctive therapy

32. Counselling S imple, widely applicable D iscussion about the problems and changes due to non nutritive sucking Show photographs, videos Scolding, nagging or frightening should be avoided because it can cause negativism.

33. BETA HYPOTHESIS(1929) d r . K night D unlop discovered the concept of negative practice. Forceful purposeful repetition of habit associates it with unpleasant reactions and habit is abandoned. When applied to oral habits a child is encouraged to watch himself in a large mirror while sucking the digit. The sight of oneself sucking thumb will hamper the pleasure derived from the activity, and the child will slowly avoid indulging in the same.

34. Reminder therapy: Indication: I n an older child of at least 6-7 years who wants to break the habit but is unable to do so Modalities 1) Chemical Method: It is less effective bitter and sour chemicals have been used over the thumb to terminate the practice. e.g., quinine, asafetida, pepper, castor oil. Now a days new anti-thumb sucking solution like femite , thumb-up, anti-thumb are also available.

35. Restrictive methods: a pplication of bandages to thumb, finger, elbow may be done . B andages on the thumb will take away the pleasure from the act. B andaging the elbow will prevent bending the elbow to suck thumb.

36. Intraoral appliances T hese appliances should be used in age group of 3 1/2 – 4 1/2 year children. Appliances like palatal bar, palatal arch, palatal crib, hay-rake, blue grass appliance, bakers modification of bluegrass appliance, quad helix, clear crib, invisalign

37. PalATAL crib O ne of the principal habit reminders . I t consists of a 0.030 inch round lingual arch wire attached to the upper first molar bands with an anterior platform T his keeps the thumb or finger from exerting pressure on the soft tissue of the palate .

38. BLUE GRASS APPLIANCE I ntroduced by Haskell (1991) c onsists of a six-sided roller made of Teflon slipped over a 0.045 stainless steel wire soldered to bands placed on molars. T he roller is placed in most superior aspect of the palate and must not be in contact with the palatal tissue so that patients can roll them with their tongues. This appliance is placed for 3-6 months and in early or mixed dentition period.

39. CLEAR CRIB T he crib is fabricated from 1.5mm thermoformed acrylic sheet . I nitially vertical spikes are fabricated in the maxillary cast at the desired position using 0.036” stainless steel wire . F inal appliance is similar to an Essix /clear retainer with erupted molds of the spikes.

40. Invisalign S mall areas of the aligner are occlusally flipped like a bite ramp, in palatal surface of upper incisors, in order to discourage the habit. Widely accepted among adolescents. Duration of treatment is 8 months with no behavioral therapy.

41. Disadvantages: 1) a period of emotional upset until they get used to the appliance 2) s peech being affected temporarily 3)d ifficult in eating with the use of fixed orthodontic habit breakers 4)i ncrease tendency for caries 5) Decalcification of enamel surfaces 6)g ingival inflammation may occur

42. TONGUE THRUSTING, SWALLOWING HABIT OR RETAINED INFANTILE SWALLOW: T he tongue is a powerful muscular organ which exerts tremendous pressure during swallowing at frequent intervals, 24 hours a day, during the sleep time as well as during the day . N ormal mature swallowing takes place without contracting muscles of facial expression . T he teeth are momentarily in contact and tongue remains inside the mouth T ongue thrust is the placement of the tongue tip forward between the incisors during swallowing Tongue thrusting habit: A review Suchita Madhukar Tarvade , Sheetal Ramkrishna International Journal of Contemporary Dental and Medical Reviews (2015), Article ID 151214, 5 Pages

43. I n tongue thrusting habit, a normal sized tongue or one that is overdeveloped thrusts between the upper and lower teeth each time the patient swallows producing an open bite. Sometimes the patient allows the tongue to rest in the open bite space between the act of deglutition, preventing the bite from closing. Rix(1953) recognised two sharply contrasting types of tongue behaviour: 1) Non dispersing behaviour of the tongue : those cases in which the tongue does not come forward to exert any force on the lingual surface of upper and lower incisors.

44. The lips may or may not contract excessively The upper and lower incisors are upright or retroclined. 2) D ispersing behaviour of the tongue: T hose cases in which the actions of tongue and lips are associated with a dispersal of upper and lower incisor relations .

45. Causes of tongue thrusting: Maturational factors : t ongue thrust may develop as a sequel of prolonged thumb sucking and retained infantile swallow . A transitional period from infantile swallow to mature swallow also exhibits tongue thrusting. ANATOMIC FACTORS: In macroglossia, there is overgrowth of the tongue. Pressure is exerted against the lingual surfaces of the teeth causing them to become spaced.

46. Indentations on the tongue often appear where tongue pushes against the teeth. Adenoids or tonsils cause the tongue to be positioned anteriorly to prevent blocking of the oropharynx. Tongue thrusting is also called an adaptive behaviour. If large spaces are present anteriorly between upper and lower teeth, then tongue will try to move into these spaces to achieve the anterior seal. Occlusion- o pen bite in deciduous dentition caused by tongue dysfunction as a residuum of a sucking habit.

47. Habitual position: T he tongue is positioned forward during functioning thus impeding the vertical development of the dentoalveolar structures around the upper and lower anterior teeth. NEUROGENIC FACTORS: Hyposensitive palate causes the tongue to be pushed forward. CONFIGURATION OF THE CRANIOFACIAL SKELETON AND DYSFUNCTION The morphology of the facial skeleton and the effects of tongue thrusting are correlated to a certain degree.

48. a horizontal growth pattern in conjunction with tongue thrust usually results in a bimaxillary dental protrusion I n vertical growth pattern with tongue thrust the lower incisors are in lingual inclination . UPPER RESPIRATORY TRACT INFECTION MOUTH BREATHING CHRONIC TONSILLITIS HYPERTONIC ORBICULARIS ORIS MUSCLE

49. Classification (JAMES Braner and hoLt ) type I : N on deforming tongue thrust type II : D eforming anterior tongue thrust ‘ Subgroup 1: anterior open bite Subgroup 2: anterior proclination Subgroup 3: posterior cross bite TYPE III : Deforming lateral tongue thrust Subgroup 1: posterior open bite Subgroup 2: posterior cross bite Subgroup 3: deep bite

50. Type iv: d eforming anterior and lateral tongue thrust subgroup 1: a nterior and posterior open bite subgroup 2: p roclination of anterior teeth subgroup 3: p osterior cross bite

51. Classification Simple tongue thrust: f eatures: Normal tooth contact in posterior region Anterior open bite Contraction of lips, mentalis muscle and mandibular elevators LATERAL TONGUE THRUST: Features: Posterior open bite with tongue thrusting laterally COMPLEX TONGUE THRUST: Features: Generalized open bite Absence of contraction of lip and muscle Teeth contact in occlusion

52. TYPES OF TONGUE THRUSTING: 1. Physiologic tongue thrust: D uring infantile swallow the tongue is placed between the gum pads. After six months of life, several maturational events occur that alter the functioning of orofacial musculature. With the arrival of incisors the tongue assumes a retracted posture. If the transition of infantile to mature swallow does not take place with the eruption of teeth then it leads to tongue thrust swallow.

53. 2. HABITUAL TONGUE THRUST: It is present as a habit after the correction of the malocclusion. 3. FUNCTIONAL TONGUE THRUST: It develops to achieve an oral seal 4. ANATOMIC TONGUE THRUST: It occurs due to macroglossia

54. Clinical features of tongue thrusting swallow: T he clinical features seen in the tongue thrusting condition are dependent on the type of tongue thrusting: Simple tongue thrusting: Generalised spacing and proclination can be seen in the upper and lower anterior teeth. Increased overjet, reduced overbite or presence of anterior open bite may be seen. Exaggerated perioral musculature activity during swallowing action

55. 2) C omplex tongue thrusting : T he teeth are apart during the swallowing process. The tongue spreads laterally in between the upper and lower teeth Lateral tongue thrusting is seen in such cases. Unilateral crossbite may also be seen.

56. METHODS OF EXAMINATION V arious methods can be used to examine tongue dysfunctions. Extraoral examination shows an exaggerated perioral contraction during swallowing. Increased vertical dimension of face due to over eruption of the molars into the freeway space is evident. Intraoral examination shows appearance of open bite and spacing between the teeth. A forced tongue may cause gushing of saliva through the spaced dentition. The different types of clinical examination are: electronic recordings of the pressure exerted by the tongue intraorally, roentgenocephalometric analysis, cineradiographic, palatographic and neurophysiologic examinations.

57. The position and size of tongue in relation to the available space can be assessed using roentgenographic cephalometrics. H owever, in most orthodontic cases registering the position of the tongue is more important than determining its size.

58. PALATOGRAPHY involves recording the contact surfaces of the tongue with the palate and teeth while the patient produces speech sounds or performs certain tongue functions. A thin uniform layer of contrasting precise impression material is applied to the patient’s tongue with a spatula. Once the consonant has been pronounced or the tongue movement carried out(e.g. swallowing), the palatogram can be documented photographically using a surface mirror.

59. Palatogram during the pronunciation of “s” ACCURATE PRONUNCIATION OF “S”: D uring articulation, the mandible is lowered slightly and pushed forwards. The tongue rests on the teeth and the alveolar processes, and a groove is formed in the centre through which the air stream is directed onto the central incisors. INTERDENTAL SIGMATISM(LISPING): During this defective pronunciation of the “S” sound, the tongue is usually protruded and clearly visible between the anterior teeth.

60. Palatal sigmatism T he abnormal pronunciation is caused by an unphysiologic friction noise between tongue and hard palate . LATERAL SIGMATISM ON THE LEFT SIDE T he tongue rests on the anterior teeth. The column of air escapes on the left side.

61. BILATERAL SIGMATISM Palatogram of this type of defective articulation in a patient with macroglossia. Sigmatism due to lateroflexion to the left side : D uring this inaccurate formation of the ‘s’ sound, the tip of the tongue is raised too high and rests on the upper incisors. T he tip of the tongue deviates to the left of the midline and the air stream is forced laterally .

62. METRIC EVALUATION OF TONGUE POSTURE A ssessment of tongue position on the lateral cephalogram 1 = I ncisal edge of the lower central incisor M c = cervical distal third of the last erupted molar V = the most inferior point of the uvula, respectively its projection on the reference line (connecting line between is 1 and Mc) O = Midpoint on the reference line between is 1 and V A line is drawn through O perpendicular to the horizontal baseline, and extended to the palate. A further four lines are drawn at 30 degree to each other resulting in a total of seven lines.

63. Tracing of the analysis on the lateral cephalogram: m arking of the contours of the bony palate and dorsum of the tongue. Horizontal and vertical reference lines for metric evaluation Left: The morphologic relationships in case of a retracted, elevated tongue Right: Relationships in case of a downward and forward tongue posture

64. Transparent plastic template with an inscribed millimeter scale for analyzing the position of the tongue on the lateral cephalogram.

65. INTERCEPTION AND TREATMENT OF TONGUE THRUSTING: I nterception and treatment of tongue thrusting is age and severity dependent. In children below three years, no active intervention is instituted while children above this age can be trained for tongue swallowing exercises. Tongue thrusting treatment would necessitate that anatomic obstruction like enlarged macroglossia and tonsils are also taken care of. An abnormally enlarged tongue could be due to the tumours/cysts in the floor of the mouth. These should be investigated and treated accordingly.

66. Treatment considerations of tongue thrust It requires a positive attitude and strong desire by the patient to overcome abnormal habit along with suitable mechanotherapy Reminder therapy: Palatal appliances- palatal cribs, spurs, palatal rolling ball, Nance palatal arch appliance Corrective therapy: 1) Removal of obstruction: Surgery of adenoids, macroglossia 2) Closure of anterior open bite, posterior open bite and/or anterior spaces with either a fixed or removeable orthodontic appliance. AGE: T ongue thrust often corrects itself by 8 or 9 years of age. Self correction is due to improved musculature balance during swallowing. Presence and absence of associated manifestation: Treatment is not recommended when tongue thrust is present without malocclusion or a speech problem.

67. Training the tongue for correct swallow and posture Tongue exercises: ELASTIC BAND SWALLOW The elastic band is kept on the tip of the tongue against the palate and swallowing is practised. WATER SWALLOW To keep water in mouth and a mirror in hand and swallowing is practised daily. CANDY SWALLOW A candy is placed between the tongue and palate and swallowing is practised SPEECH EXERCISES Patient practises syllables like c, g, h, k while keeping an elastic band between the tongue and palate

68. 4) Lips exercises Patient practises stretching of lips so as to achieve anterior lip seal Myofunctional exercise: T he child is asked to place the tip of the tongue in the rugae area for 5 minutes 4 S exercise - it includes identifying the spot - salivating - squeezing the spot - swallowing Ask the child to perform series of exercises like whistling, reciting count from 60 to 69, yawning to tone the muscle f ixed habit breaking appliance with tongue crib can be given. For posterior open bite modified habit crib is used.

69. MOUTH BREATHING HABIT T he mode of respiration is examined to establish whether the nasal breathing is impeded or not. Chronically disturbed nasal respiration represents a dysfunction of the orofacial musculature it can restrict development of the dentition and hinders the orthodontic treatment. The obstruction may be temporary and recurrent. While more often it is partial then complete. The airway resistance may be enough to force the subject to breath through mouth.

70. Causes of obstruction to nasal passages are: 1) Allergic rhinitis 2) enlarged tonsils or adenoids 3) deviated nasal septum 4) Nasal polyps 5) Enlarged nasal turbinate's

71. Clinical features T he term respiratory obstruction syndrome was used to describe the constellation of characteristic features associated with obstruction of the nasal airway during the years of facial growth. Other common terms for mouth breathers are long face syndrome and vertical maxillary excess The clinical features are: Excessive lower anterior face height Incompetent lip posture Excessive appearance of maxillary anterior teeth, ‘gummy smile’

72. 4. A nose that appears to be flattened, nostrils that are small and poorly developed 5. Steep mandibular plane 6. Posterior crossbite 7. O pen mouth posture 8. A short upper lip and a fuller lower lip 9. A narrow shaped upper jaw with a high narrow palatal vault 10. A class II skeletal relationship 11. Gingivitis of upper anterior teeth

73. All these features contribute to ‘adenoid facies’ Adenoid Facies was the term coined by tomes(1872) to describe dentofacial changes associated with chronic nasal airway obstruction

74. DIAGNOSIS OF MOUTH BREATHING : History – F rom family/parents Check for clinical features of adenoid facies Various test can be performed for diagnosis of mode of respiration Water holding test: Patient is asked to hold water in his mouth. Instability to keep the mouth closed for more than 2 minutes confirms nasal obstructions and therefore mouth breathing habit.

75. 2. Mirror condensation test: A two surface mirror is placed under the nose. If the upper surface condenses, then breathing is through the nose, but if the condensation occurs on the lower surface then breathing is through the mouth 3. Cotton wisp test: A small wisp of cotton (butterfly-shaped) is placed below the nostrils in a butterfly shape. If the upper fibres are displaced then the breathing is through the nose. If the lower fibres are displaced then it is mouth breathing habit.

76. EXAMINATION OF ALA MUSCULATURE T he size and shape of the external nares of a patient with nasal respiration during inspiration and expiration. The very noticeable changes in cross-section of the nasal orifices are typical for nasal breathers. The mirrors are held in front of both nostrils. In nasal breathers the mirror will cloud with condensed moisture during expiration The very noticeable changes in the cross-section of the nasal orifices are typical for nasal breathers

77. In oronasal respiration alar muscles are inactive nares do not change their size which is clinical feature of increased oral respiration. The alar muscles are inactive- nares do not change their size- which is a clinical feature of increased oral respiration. Clinical feature of increased oral respiration

78. C lassification of adenoids on the lateral cephalograms Small-sized adenoids: The radiographic image of the adenoid on the lateral cephalogram appear as a slight curvature on the upper rear wall of the nasopharynx. Medium-sized adenoids: noticeable proliferation of lymphoid tissue Large-sized adenoids: the lymphatic tissue occupies most of the nasopharyngeal pneumatic cavity.

79. TREATMENT OF MOUTH BREATHING T reatment consideration T here are various factors which should be considered during treatment of mouth breathing habit . T hey are as follows: A ge of child : M ost of the time mouth breathing habit is self-correcting after puberty . ENT examination: A n otorhinolaryngologist examination may be advised to determine whether conditions which require treatment are present in the tonsils, nasal septum or adenoids. I f the mouth breathing habit continues even after the removal of cause then it is habitual.

80. P revention and interception : M outh breathing can be intercepted by use of an oral screen . R emove the cause : E tiological agents for mouth breathing habit should be treated first . I f any nasal or pharyngeal obstruction is present then removal of obstruction by surgery or local medication should be pursued . I f a respiratory allergy is present, it should be brought under control. I ntercept the habit : I nterception of habit is very important. even after the removal of the obstruction if the habit continues then it should be corrected .

81. METHODS OF CORRECTION Exercises V arious exercises are recommended for correction of mouth breathing habit. it includes : a) H old a sheet of paper between the lips . b) P atients with short hypotonic upper lip should stretch the upper lip to maintain lip seal or stretch in downward direction toward the chin . c) B utton pull exercise: a button of 11⁄2” diameter is taken and a thread is passed through the button hold . T he patient is asked to place the button behind the lip and pull the thread, while restricting it from being pulled out by using lip pressure .

82. d) T ug of war exercise : T his involves two buttons, with one placed behind the lips while the other button is held by another person to pull the thread . B low under the upper lip and hold under tension to a slow count of 4 repeat 25 times a day . D raw upper lip over the upper incisors and hold under tension for a count of 10.

83. Oral screen I t was first introduced by Newell in 1912. I t is a myofunctional appliance that is easy to fabricate and easy to wear . I t works on the principle of both force application and force elimination . P rinciple of oral screen : I t is a functional appliance which produces its effects by redirecting the pressures of the muscular and soft-tissue curtain of the cheeks and lips. I t works on the principle of both force application and force elimination. F or example, anterior teeth proclination can be corrected utilizing the principle of force application . T he screen comes in contact with the proclined teeth so that the forces from the lips are transmitted directly to the proclined teeth through the screen.

84. Posterior cross bite can be corrected utilizing the principle of force elimination by providing a spacer between the teeth and the screen . Rapid maxillary expansion (RME) P atients with narrow, constricted maxillary arches benefit from RME procedures aimed at widening of the arch . I t increases nasal air flow and decrease nasal air resistance . I ncrease in intranasal space occurs due to outer walls of nasal cavity moving apart.

85. Lip habits: T he various habits can be divided into lip sucking and lip insufficiency Lip dysfunctions can be observed while the patient is speaking and swallowing The lower lip and tip of the tongue are often in contact. In such cases, the lower lip is sucked in and pressed against the tip of the tongue Lip sucking: the lower lip is positioned behind the upper incisors. In many patients malpositioning of the lips occurs in conjunction with hyperactivity of the mentalis muscle.

86. L ip thrust : C haracteristic profile of the lower third of the face in case with hyperactivity of the mentalis muscle. I n many patients this type of lip habit is combined with the lingual inclination of the incisors. Lip sucking habit can be eliminated by lip pads in the lower arch

87. Cheek dysfunctions: i n case of cheek sucking or cheek biting the soft tissues are interposed between the occlusal surfaces of the teeth, which promotes the formation of a lateral open bite or a deep overbite . I ncreased lateral pressure by the cheek musculature on for example the mandible impedes the transverse development of the jaw T his type of cheek dysfunction is common in cases with buccal nonocclusion

88. HYPERACTIVITY OF MENTALIS MUSCLE T he deep mentolabial sulcus is a characteristic of hyperactive mentalis muscle . T his habitual pattern of muscle behavior impedes the forward development of the anterior alveolar process in the mandible T he abnormal mentalis function often occurs together with lip-sucking or lip thrust . T he hyperactive mentalis muscle pulls the lower lip upward and rearward and presses it against the lingual surfaces of the upper incisors .

89. T he upper lip remains relatively motionless T he normal lip seal is disturbed and the tongue is displaced downward T his type of soft tissue morphology aggravates the dentoalveolar malocclusion .

90. BRUXISM: B ruxism in the simplest terms refers to the clenching and gnashing of the teeth against each other. Ramfjord and Ash described it as nocturnal subconscious activity but can occur in the day or night and may be performed consciously or subconsciously. Sleep bruxism is an entity that is very common with children. The adult may bruxise in either day or night .

91. etiology E motional tension seems to be the major cause O cclusal interferences such as faulty restorations Childhood bruxism is related to other oral habits such as chronic biting and chewing of toys and pencils, thumb and finger sucking, tongue thrusting and mouth breathing. Nutritional and vitamin deficiencies Athletes indulge in bruxism due to increased muscular activity Neurologic disturbances like epilepsy, lesions in cerebral cortex

92. Clinical features T eeth that are abnormally worn down, flattened or chipped Atypical occlusal facets – worn tooth enamel, exposing the dentin of the tooth Increased tooth sensitivity Jaw pain or tightness in the jaw muscles Earache because of severe jaw muscle contractions Headache and chronic facial pain Hypertrophy of masseter muscle Teeth grinding and clenching

93. Treatment Psychological counselling to identify and treat any psychological distress, tension or emotional upset Correction of any occlusal interferences by coronoplasty Temporary relief can be brought by bite plates or occlusal splints that will help in relieving the pain in muscles Oral analgesics for muscular pain

94. Physiotherapy has proven useful in relieving the symptoms of bruxism Low intensity ultrasonic radiation therapy, Accupressure /acupuncture Transcutaneous electric nerve stimulations(TENS)

95. NAIL BITING Nail biting usually develops after the sucking age i.e after 3 yrs of age. It does not assist in the production of malocclusion since the forces or stresses applied in nail biting are similar to those in the chewing process. However in certain cases of nail biting a marked attrition of the lower anterior teeth, crowding and rotation have been observed.

96. O nychophagy is a nail disease caused by repeated injuries of nails . The need to bite or eat fingernails is related to a psycho emotional state of anxiety . A nail biting child is exhibiting an evolutionary disturbance related to the oral stage of psychological development (Pearson GHJ, 1948)

97. a bout one forth of patients with temporomandibular joint pain and dysfunction have been shown to suffer from nail biting habit T reatment putting nail polish or distasteful liquids on nails

98. SELF – MUTILATION / SELF-INJURIOUS HABITS S elf-mutilation, results in physical damage to the individual, and is extremely rare in the normal child . T he incidence of self-mutilation in the mentally retarded population is between 10 and 20%. S elf-mutilation is a learned behavior which manifests biting of the lips, tongue and oral mucosa.

99. A ny child who willfully inflicts pain or damage to himself should be considered psycho-logically abnormal . Self-mutilation has also been associated with disorders, such as Lesch-NyAN syndrome I t is associated with biting tongue and lips initially followed by finger biting and head banging

100. CONCLUSION A bnormal pressure habits changes the alveolar bone and regulate teeth because the bone-building cells on the receiving end of pressure or stimulus cannot differentiate whether that pressure or stimulus is intentional or unintentional . T he face, with its cartilaginous bone, yields easily to stimulus and pressure, especially during growth spurts, and presents the most complicated growth problem in the entire skeleton . S ince the greatest growth changes in the head are being made by the facial structures, it logically can be assumed, therefore, that all abnormal pressures should be kept away from its most vulnerable target.

101. REFERENCES: T extbook of contemporary orthodontics By Profitt 6 th Edition Orthodontic Diagnosis – Thomas Rakosi , Jonas And Graber T extbook of orthodontics – O mprakash K harbanda J onathan Gillis (1996). B ad habits and pernicious results : T humb sucking and the discipline of late-nineteenth-century paediatrics . medical history , 40, pp 55-73 Haskell BS, Mink JR. An Aid To Stop Thumb Sucking: The “Bluegrass” Appliance . J ournal of clinical orthodontics 1991;13(2):83–85 .

102. THANK YOU!